Emergency Screening Form

Emergency Screening Form

As of the 4th January 2022, we may experience some staff shortages. The phone may not be answered during this time. Please complete the form below and a staff member will be in touch with you as soon as possible. We appreciate your patience and understanding at this time.
Name *
Address *
Date of Birth *

Day Month Year
Date
Phone Number *
Email
example@example.com
PPS Number
Please Select Which Dental Practice You Attend *

Dr. Padraig O'Reachtagain, Roscrea Previously a patient of Dr. Gerry Browne, Birr
Have you been advised by the HSE or your General Medical Practitioner to self-isolate? *

Yes No Other
In the past 14 days, have you had or do you currently have any of the following: *

High Temperature Shortness OfBreath/Difficulties Breathing Cough A Household contact of a Covid 19 Positive Patients Awaiting results of a PCR Test None of the above
Are you allergic to penicillin? *

Yes No Other
Are you allergic to any other medication? If soplease specify *

Yes No Other
Name of your pharmacy
Are you pregnant?

Yes No Maybe
The following are considered as dental emergencies, please select which applies to your current situation:

Swelling of face and/or neck associated with yourmouth Acute dental pain causing you not to sleep An accident or trauma which has caused the teeth to move preventing you from closing your teeth I don't have an emergency, can you please call me back
Please specify the nature of your emergency and any other additional information we should be made aware of including illnesses and current medication:
Please specify the location of pain / broken tooth/ trauma:

Top jaw Bottom jaw Left side of your face Right side of your face Towards back of your mouth Towards front of your mouth Other
Is the tooth

Painful to touch or bite on Sensitive to cold Sensitive to hot Cutting your tongue Other
Upload a picture. i.e. broken tooth / swelling etc. (Optional)

Cancel of
Signature

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